Acute Nephritis.
Synonyms:—Acute parenchymatous nephritis; acute diffused nephritis; exudative nephritis; tubal nephritis; acute catarrhal nephritis; acute Bright's disease.
Definition:—An acute inflammation of the kidneys involving all the structures of the organ.
Etiology:—Acute nephritis seldom occurs after middle life. As it results from exposure or injury, or from violent physical exertion, young males are more subject to it than other individuals. It occurs quite commonly in childhood, but in these cases it usually results from some other disease, notably those of infectious origin, such as typhoid, typhus or relapsing fever, scarlet fever, diphtheria, smallpox, la grippe, measles, erysipelas or septic infection. The kidneys may be directly infected, and thus induce a primary infectious, nephritis.
Direct exposure to cold, and consequent acute renal congestion, is a common cause of the development of this disease. Alcoholics are especially liable and those whose habits are irregular and dissipated in character. Those toxic agents which have been mentioned as the possible causes of renal congestion are also the causes of acute inflammation of the renal organs. Another common cause is serious scalds or burns upon the surface of the body, or skin disease which involves a large area, thus throwing an unusual amount of labor upon the kidneys and at the same time inducing the excretion of toxins which result from the skin lesion.
The gravid uterus displacing the abdominal contents and compressing the arterial circulation induces acute renal congestion, which quite frequently develops into nephritis. There are blood changes that take place during pregnancy also that facilitate the occurrence of this disease.
Symptomatology:—In its primary form, when occurring from exposure to cold or from direct traumatism at the onset, the symptoms may so closely resemble those of acute hyperemia that a distinction between the two conditions is made with difficulty, if at all. These symptoms differ from those which appear when the condition follows other diseases or occurs as a result of septic infection. This constitutes two groups of symptoms, which must be considered separately. The symptoms differ somewhat also in adults and in children.
The descriptions of the symptoms which I here present are taken from the histories of typical cases which have occurred in my own practice.
The patient, with but little premonition, except perhaps that he has suddenly contracted a severe cold, usually from some known exposure, with the usual symptoms and severe aching of the muscles of the back, is taken with a sharp chill, accompanied with nausea, vomiting, which may be quite persistent, and severe pain across the loins. Or, if the primary congestion attacks only one kidney, the pain will be located in the affected side. Concurrently with these symptoms is the rapid rise of temperature to from 102.5° to 104.5°, with great restlessness and perhaps mild delirium. The skin is hot and dry, the face is flushed, the pupils contracted and sensitive to light, and there may be epistaxis. The pulse is sharp, hard and from 105 to 120 beats per minute, medium full at first, but subsequently small, hard and often wiry.
The attention is attracted to the urinary irritation. There is frequent urination, with small, sharp cutting pains in the urethra, and the passage of a small quantity of urine only at each time, with tenesmus and almost constant desire. The urine is loaded with urates or is of a dark, smoky or wine color from the presence of blood, has a specific gravity of from 1,026 to 1,034, and contains much albumin and casts. These symptoms confirm the diagnosis and suggest the immediate course of treatment.
With these symptoms an immediate full comprehension of the case in all its seriousness and positive, direct treatment may ward off any dropsical symptoms. If, however, these appear, they may be delayed until the morning of the third day. The patient's face will by this time have lost its flushed appearance and there is a puffiness under the eyes, or the hands, feet and ankles may be swollen. This may increase with some rapidity to general dropsy, but in favorable cases the edema will not advance beyond dropsy of the legs and feet. There may be no convulsions with these symptoms, or the uremic symptoms may appear with the edema.
When acute diffuse nephritis appears as the sequel of scarlet fever, diphtheria or other acute infectious disease, it will be observed that the patient, during what was thought to be convalescence from that disease, has increased in pallor, as anemia may develop rapidly, and with the pallor the face becomes suddenly edematous, and very soon there is general anasarca. I have observed abdominal dropsy to occur in one night to extreme distention, with no puffiness of the face, but rather a shrunken appearance and a dusky pallor of the countenance. The urine is suddenly almost completely suppressed and very albuminous, but in these cases it may contain no blood, the color being somewhat lighter than usual. There is apt to be vomiting, and but a slight fever, probably not above 101.5°, with a small, hard but feeble pulse. The patient is listless, dull, indifferent and inclined to stupor, with perhaps increasing delirium. Suddenly convulsions appear with an increase of all symptoms. There may be no pain in the back complained of and no urinary irritation.
In nephritis from acute toxemia, and in those cases which I have observed to follow rapid septic absorption after a miscarriage or after confinement, there may be absolutely no symptoms before it is observed that there is complete suppression of urine. After from twelve to eighteen hours convulsions and rapid evidences of uremic intoxication appear, unless the most active measures are adopted at the onset.
In puerperal eclampsia the convulsions may be the first evidence of wrong, and these may persist in spite of the most urgent measures, until death. Usually, however, the nephritis of pregnancy is somewhat insidious and gradual at its onset and continues to increase until the confinement has passed. Convulsions constantly menace the patient as long as albuminuria exists. There may be no backache, but severe headache and nausea. I recently had a case in which a primipara developed all the symptoms, in a classic form before the end of the third month, with extreme backache, almost persistent headache, puffiness of the face, vomiting and scanty, albuminous urine. These all abated under direct treatment, and there were no evidences whatever of the nephritis at the seventh month. The confinement at full term lasted but three hours and was uneventful. I attributed this case to cold, more than to the usual pressure causes.
There is a class of these cases where the cause is obscure, when the disease approaches insidiously, with absence of pain or discomfort, but rapidly increasing pallor. The skin is dry, the mouth is dry; although there is but slight fever, the bowels are constipated. There is edema of the eyelids and general edema increases rapidly, with dyspnea and general distress. In those cases where the dropsy is the pronounced symptom it will become general rapidly, often assuming the form of hydrothorax and hydropericardium, with great oppression of breathing as well as with extreme ascites. Occasionally it involves the soft palate, larynx or glottis.
The urine in acute nephritis varies in the different forms, but is usually scanty, from six to twelve ounces in the twenty-four hours, with at first increased and subsequently diminished specific gravity. The urea is notably diminished. The microscope shows crystalline solids and debris, red cells, disintegrated cells, epithelial cells from the tubules, blood hyaline and epithelial tube casts in abundance. The reaction is usually acid, especially early in the disease. The albuminous precipitate is white, if no blood be present. If there is blood, the sediment is brown, dark brown or black. It may vary in weight from one-half to two per cent of the total urine.
There is much variation in the symptoms in the cases above described, and there may be cases where the symptoms are very confusing, while in other cases, as stated, there may be almost an absence of symptoms until extreme dropsy without uremia, or uremia without dropsy, appears, or convulsions without dropsy and with few other evidences of uremia occur.
With modern methods of investigation no physician is excusable for not keeping the closest watch upon susceptible cases for the least evidence of the appearance of this disease.
Diagnosis:—In the first class described, the local pain, scanty urine and urinary irritation are the symptoms that point most strongly to the actual seat of the disease until revealed by urinary analysis.
In other cases edema of the face and eyelids, scanty or deficient urine, extreme headache with some mental confusion, pallor of the face, muscular twitchingss, with perhaps dyspnea, will suggest the cause, which is confirmed by an analysis.
During pregnancy there may be a transitory, cyclic or irregular appearance of a small quantity of albumin in the urine, with no casts nor blood corpuscles. This is not nephritis. It is a temporary congestion, which, however, must not by any means be passed by.
The casts with albumin are proof positive. These are hyaline, granular, epithelial or blood casts. The urine in pregnancy may be deceptive, as it is apt to be of nearly full quantity, pale and of low specific gravity and the quantity of albumin not large.
Prognosis:—Nephritis occurring primarily is more amenable to treatment than the induced form of the disease. The prognosis in the nephritis of pregnancy is good, the serious cases are those that are insidious in their onset, the postscarlatinal or post-diphtheritic cases, and those which result from sepsis. Those in which the dropsical effusion is sudden and rapid, and especially if accompanied with dyspnea, should have a guarded prognosis.
Sudden and more or less complete suppression of the urine is always very serious, and must have no temporizing in the treatment. This disease will run its course in from six to nine days, and if properly treated should result in a perfect cure. Many cases of the chronic form of the disease follow an acute attack.
Treatment:—In the treatment of this disease, which is always serious, its cause, if possible, and the manner of its development must be determined, and these conditions will determine the character of the treatment. The seriousness of the disease must be fully appreciated at once, and there must be no temporizing. The most active measures must be immediately resorted to. The patient should have a thorough hot foot bath, and free transpiration from the skin should be induced. He should be then wrapped in blankets and put into a warm bed, and hot applications must be persistently applied to the kidneys to overcome the preliminary congestion.
The tendency to chilliness, with high temperature, will suggest aconite. Not only will nervous irritability, a flushed face and contracted pupils suggest gelsemium, but in the absence of these symptoms it must be given if the cerebral condition does not positively contraindicate it, for its direct specific influence upon the capillary circulation of the kidneys through the nervous structures of those organs. One who has never used this remedy cannot appreciate the benefit derived from it. It reduces nerve irritation, thus permitting dilatation of the capillaries, which results in a rapid relief of the local engorgement; this influence is contributed to by the effect of the external heat. The remedy may be given in conjunction with aconite, as above specified, and if there is much muscular aching, a most valuable co-operative agent is cimicifuga.
These remedies, if continued, will materially abate the main symptoms; however, if dropsy appears, it will be necessary to administer apocynum, in small doses. I much prefer the distilled extract of this remedy, as it exercises its specific influence with a minimum of gastro-intestinal irritation. If with the administration of aconite the skin is yet persistently harsh and dry, and the mucous membrane of the mouth is dry, five drops of jaborandi should be given every two hours. Or, if the patient is sthenic, and the symptoms at the onset are those of extreme suppression of all secretions, with an engorged condition of the capillary circulation, with a flushed or purplish face, with dry, hot skin, full, strong pulse and high temperature, it is good treatment to administer, with the very first measures, a hypodermic of from one-eighth to one-fourth of a grain of pilocarpin, and continue the jaborandi subsequently if the indications should persist.
Occasionally in somewhat sluggish or plethoric cases, small doses of podophyllum with phytolacca will be needed. If there is much cerebral excitement, with active delirium, hyoscyamus in full doses must be given. If there is a tendency to fulness of the cerebral circulation, four or five hourly doses of five drops of ergot should be administered.
Where dropsy is the first indication, the patient should have a preliminary full dose of magnesium sulphate, to be followed by small doses frequently repeated of apocynum, or a mixture of five drops of specific elaterium, in four ounces of water, a teaspoonful every hour. Notwithstanding much argument to the contrary, I am confident that these cases, when accompanied with anemia, are benefited by the administration of some absorbable salt of iron. I perfer the carbonate, but where there is an indication for acids, the tincture of the chlorid of iron may be given. If the temperature should be high, without general capillary engorgement, ferrum phos should be given.
I am averse to the use of stimulating diuretics. I have had such satisfactory results without these diuretics that I am in favor of such a course. Those remedies that soothe the kidneys facilitate the removal of the pathological conditions and the restoration of the normal functional action.
In those cases where convulsions appear early, that condition must have immediate treatment, but the kidneys must not be neglected. Heat should be at once applied over the kidneys and persisted in, and the patient should have a large, hot, normal salt enema. The use of veratrum for the convulsions exercises an influence upon the kidneys similar to that of gelsemium. I prefer this course to the administration of chloroform or ether, because the anesthetics are in part eliminated through these organs, and induce irritation. I materially object to the use of morphin, because it increases the local congestion. Chloral per rectum is a safe relaxant, especially if the normal salt solution be given. The compound tincture of lobelia and capsicum, now nearly obsolete, will often control these convulsions without renal irritation.
Where sudden suppression of urine is the first conspicuous symptom, the measures just advised must be used most diligently, the hot bath and hot applications being especially essential. No stimulating diuretics must be given, but the patient may take freely of hot water. Active transpiration from the skin must be sustained, until the kidneys are acting with sufficient freedom, if this should require two or three days. Under these circumstances uremia must be anticipated. The patient should have fifteen minim doses of specific echinacea every two hours, until all danger is passed, whatever the other treatment. As the patient improves and the renal function is in part restored, mild diuretics, such as triticum, epigea, althea or verbascum, may then be given. If during apparent favorable progress of the disease puffiness of the face or dropsical effusions elsewhere appear, haircap moss or apis may be given. Renal irritation will be allayed with these remedies, and with hydrangea or cornsilk.
The use of belladonna in drop doses, every two hours, alternated every hour with one grain of santonin, as suggested under renal congestion, will prove very satisfactory, where the suppression occurs after diphtheria or scarlet fever. If dropsy be present under these circumstances, the addition of an infusion of digitalis, one dram of the leaves to a pint of water, given in teaspoonful doses every hour or two, will be found to be good treatment.
The diet of these patients is very important. At first they should have only hot milk; later this may be taken with toast, or the patient may have hot beef tea. As recovery progresses, the use of buttermilk and whey is beneficial, and raw eggs beaten, either given alone or with milk, will be of value, but any beverages that contain alcohol must be rigidly proscribed. Meat broths and gruels may be allowed, and later, thick soups or purees, but milk should be depended upon. Still later, prepared foods, cereals, a small piece of juicy beefsteak, or meat juices, may be permitted.
Active measures should be taken to restore the general tone of the patient, and the function of every organ of the body must receive attention. The tendency to chronicity in this disease is very great and can be prevented by perfect action of the nervous system, stomach, intestinal canal and liver.
To prevent subsequent renal congestion, to which these patients are very susceptible, I advise that a flannel band be worn around the body except in hot weather. This should be fastened tightly around the hip bones and should extend as high as the epigastric region. Hydrastis, nux vomica and iron, in small doses, should be continued until the patient is entirely restored. If the disease occurs in cold weather, and the results of the treatment are otherwise satisfactory, it is sometimes advisable to remove the patient as soon as possible to a warm climate, until winter has passed.
